Should pilots be replaced by lower-cost pilot assistants?

As the Wall Street Journal reports, there’s a growing shortage of qualified pilots in the US, driven by both economic reality and federal policy.

Pilots typically start their professional careers at small, regional airlines—airlines that pay, approximately, fast-food wages. Less than that, really– for for the hours they work, many pilots make less than minimum wage. After a few years, these pilots have enough flight time and experience to try to get jobs with the big carriers, for a substantial increase in salary. Once the promotion to “captain” of a commercial jet comes through, pilots can make $200,000 or more a year.

But the system is getting wobbly. The two-tiered payment system relies too heavily on a steady influx of new, fresh-faced pilots eager to fly at any income. And new federal regulations require that starting pilots have 1,500 hours of flying experience, up from 250 hours—meaning even more debt for young flyers.

In other words: long training for an eventually good salary isn’t likely to continue to attract enough talent. Does this remind you of any other industry?

It’s expensive to train a pilot, and it’s expensive to train a doctor. We typically spend 4 years as undergrads, 4 years in medical school, then at least 3 years at a less-than-minimum wage job (residency) just to qualify as “primary care providers” in internal medicine, pediatrics, or family medicine. If we want to make the big bucks, that’s another several years for fellowship or surgical training.

Meanwhile, there’s a push to get more people insured—more people who will want to see a doctor. As with pilots, a doctor shortage looms.

Some people are suggesting an expanded role for non-doctors—nurse practitioners, physician’s assistants, pharmacists, and others to take a larger role, perhaps to “lead the health care team.” It’s unclear what the effect of such a change will be on the quality of health care delivery, but that hasn’t stopped many health care systems from relying more on these lower-cost providers. Most of the time, with most patients, that works out fine.

I suppose we could also rely more on low-cost “pilot assistants” or “flying practitioners” as well. Most of the time, that would work out fine, too. But I don’t think most people would be happy to ride a plane piloted by a non-pilot. When people fly, they expect a real pilot to be in charge: someone with both the experience and the training not only to handle the routine stuff, but someone who can handle the rare emergencies or unexpected complications. Someone who can land any plane safely, even when things go wrong.

Physician extenders and other mid-levels can safely and effectively handle most medical questions. But the trick is knowing which patients really would do better with a physician. We don’t necessarily know ahead of time (just like we don’t know which flights will have emergencies.) Co-pilots and navigators and other assistants can be a valuable part of the cockpit team, but who will you turn to when something goes wrong?

OT, but I’m really looking forward to your comment on the recent JAMA Pediatrics article that has been all over our media the last day or two, re paracetamol/acetaminophen exposure in utero and a link to ADHD. I haven’t seen the original article, but it sure sounds like it will become another piece of well-meaning advice that pregnant women will have to put up with!

Roy Benaroch’s article about “dumbing down” of medical care as well as the art of piloting aircraft highlights Americas misunderstanding of professional value. The cost of health care in terms of dollars and suffering is related to the decisions that doctors make and the sum of the units of medical treatment that follow. While automation in piloting airplanes and practicing medicine may have reached high levels, systems are not yet sufficiently sophisticated to replace medical decisions in caring for patients nor to replace pilot decisions while flying airplanes.

Alternatives are probably still too costly in dollars and human suffering. Kudos to Dr Benaroch!

I would take exception to the term “dumbing down” of medical care used by Dr. Kardos. Since this is a pediatric blog, I would be interested to see comments from pediatricians who have collaborated or practiced with certified pediatric nurse practitioners, and parents whose children have received care from pnps. I have been a pediatric nurse for over 30 years, and have practiced as a CPNP for the past 17 years. My experience is that both pediatricians and parents have been pleased wit the care I have provided. There are certainly enough families and children needing care. As to who should “lead” the team….am not sure. The team leader ought be the professional best able to keep the team together, and functioning to provide the best patient care. With regard to who provides the care, whether it would be better for the patient to see a physician, or to see the pediatric nurse practitioner, it is very tricky, as in typical practices that decision is made by either the telephone triage nurse or the scheduler, and often ends up being based on which provider has an opening. Not a very scientific decision. We all have our likes and dislikes, areas we really love and some not so much. But balance is good for everyone. We all have limitations, and thus we all consult with each other and pediatric specialty providers. I have found, that with the right provider mix (MD’s, DO’s and CPNP’s) the team functions well, the children are well cared for and parents are happy.

And what do you say to the data that shows NP’s provide care that is equal to (or superior to!) care provided by physicians in quality and effectiveness? You need to put aside your bias and look at the evidence. I usually find your blog posts so thoughtful and full of insight. This one seems knee-jerk and poorly thought out. You missed the mark.

I happy see a NP whenever it is an option, for myself and my children. At least in case of NP’s, I haven’t seen anything proving the poor outcomes you imply are bound to happen. I’ve only come across studies showing more or less equivalent outcomes. Can you point me to something?